Treatment for cancer of the uterus

Most people with cancer of the uterus will have this operation, which removes the uterus, cervix, fallopian tubes and ovaries (as shown by the dotted line). Sometimes one or more pelvic lymph nodes are also removed to help with staging.

A pathologist examines all removed tissue and fluids. The results will help confirm the type of cancer of the uterus, if it has spread (metastasised), and its stage and grade. The cancer may also be tested for particular gene changes.

The surgery will be performed under a general anaesthetic. Your surgeon will discuss the most appropriate surgery for you, and explain the risks and benefits. The type of hysterectomy you have depends on a number of factors, such as:

• your age and build
• the size of your uterus
• the tumour size, and
• the surgeon’s specialty and experience.

Also called a laparoscopic hysterectomy, a surgeon inserts a laparoscope (thin tube with light and camera) and instruments through about four small cuts in the abdomen. The uterus and other organs are removed through the vagina.

This is a special form of keyhole surgery. The instruments and camera are inserted through about four small cuts, and controlled by robotic arms guided by the surgeon, who sits next to the operating table.

This surgery (also called abdominal hysterectomy or laparotomy) is done through the abdomen. A cut is usually made from the pubic area to the bellybutton. The uterus and other organs are then removed.

When you wake up after the operation, you will be in a recovery room near the operating theatre. Once you are fully conscious, you will be transferred to the ward.

• Tubes and drips – You will have an intravenous drip in your arm to give you medicines and fluid, and a tube (catheter) in your bladder to collect urine (wee). These will usually be removed the day after the operation.
• Length of stay – You will stay in hospital for about 1–4 days. How long you stay will depend on the type of surgery you had and how quickly you recover. Most people who have keyhole surgery will be able to go home on the first or second day after the surgery (and occasionally on the day of surgery).
• Pain – As with all major surgery, you will have some discomfort or pain. The level of pain will depend on the type of operation. After keyhole surgery, you will usually be given pain medicine to swallow. If you have open surgery, you may be given pain medicine in different ways:
  • through a drip into a vein (intravenously)
  • via a local anaesthetic injection into the abdomen (a transverse abdominis plane or TAP block) 
  • via a local anaesthetic injection into your back, either into spinal fluid (a spinal) or into the space around spinal nerves (an epidural)
  • with a patient-controlled analgesia (PCA) system, a machine that allows you to press a button for a measured dose of pain relief.

While you are in hospital, let your doctor or nurse know if you are in pain so they can adjust your medicines to make you as comfortable as possible. Do not wait until the pain is severe. After you go home, you can continue taking pain medicine as needed.

• Wound care – You can expect some light vaginal bleeding after the surgery, which should stop within two weeks. Your treatment team will talk to you about how you can keep the wound/s clean to prevent infection once you go home.
• Blood clot prevention – You will be given a daily injection of a blood thinner to reduce the risk of blood clots. Depending on your risk of clotting, you may be taught to give this injection to yourself so you can continue it for a few weeks at home. You may also be advised to wear compression stockings for up to four weeks to help the blood in your legs circulate well and prevent clots.
• Constipation – The medicines used during and after surgery can cause constipation (difficulty having bowel movements). Talk to your treatment team about how to manage this – they may suggest medicines to help prevent or relieve constipation. Once your surgeon says you can get out of bed, walking around can also help.
• Test results – Your doctor will have all the test results about two weeks after the operation. Whether more treatment is necessary will depend on the type, stage and grade of the disease, and the amount of remaining cancer, if any. If the cancer is at a very early stage, you may not need further treatment.

Your recovery time will depend on the type of surgery you had, your age and general health. In most cases, you will feel better within 1–2 weeks and should be able to fully return to your usual activities after 4–8 weeks.

If you don’t have support from family, friends or neighbours, ask your nurse or a social worker at the hospital whether it is possible to get help at home while you recover.

• Rest up – When you get home from hospital, you will need to take things easy for the first week. Ask family or friends to help you with chores so you can rest as much as you need to. 
• Nutrition –  To help your body recover from surgery, eat a well-balanced diet that includes a variety of foods. Include proteins such as lean meat, fish, eggs, milk, yoghurt, nuts, and legumes/beans.
• Work –  You will probably need 4–6 weeks of leave from work, depending on the type of surgery and nature of your job. People who have had keyhole surgery and have office jobs that don’t require heavy lifting can often return to work after 2–4 weeks.
• Driving – You will need to avoid driving after the surgery until you are able to move freely without pain. Discuss this issue with your doctor. Check with your car insurer for any exclusions regarding major surgery and driving. 
• Lifting – You may be advised to avoid heavy lifting (more than 3–4 kg) for 4–6 weeks. This will depend on the way the surgery was done.
• Bowel problems – It is important to avoid straining during bowel movements (pooing). Talk to your treatment team about the best way to manage constipation. 
• Bathing – Your doctor may advise taking showers instead of baths for 4–5 weeks after surgery
• Exercise –  Your treatment team will probably encourage you to walk the day of the surgery. Exercise has been shown to help people manage some treatment side effects and speed up a return to usual activities. Speak to your doctor about suitable exercise. To avoid infection, it’s best to avoid swimming for 4–5 weeks after surgery
• Sex –  Sexual intercourse should be avoided for about 6–12 weeks after surgery. Ask your doctor or nurse when you can have sex again, and explore other ways you and your partner can be intimate, such as massage.

• Menopause – If your ovaries are removed and you have not been through menopause, removal will cause immediate menopause. Menopause can cause significant emotional and physical changes.
• Impact on sex and intimacy – The changes you experience after surgery may affect how you feel about sex. You may notice changes such as vaginal dryness and loss of libido. If you have concerns, you may find it helpful to talk to a psychologist or counsellor.
• Lymphoedema – The removal of lymph nodes from the pelvis can stop lymph fluid draining normally, causing swelling in the legs or, sometimes, the vulva. This is known as lymphoedema. The risk of developing lymphoedema is low after most operations for cancer of the uterus, but the risk is higher if you have had a full lymphadenectomy followed by external beam radiation therapy. Symptoms may appear gradually, sometimes years after the treatment.
• Vaginal vault prolapse – This is when the top of the vagina drops towards the vaginal opening because the structures that support it have weakened. Having a hysterectomy does not appear to increase the risk of vaginal vault prolapse in women without pelvic floor issues. Prolapse is more commonly caused by childbirth and weak pelvic floor muscles. Doing pelvic floor exercises several times a day can help to prevent prolapse. Talk to your treatment team about doing these exercises.

Internal radiation therapy may be used after a hysterectomy to deliver radiation directly to the top of the vagina (vaginal vault) from inside your body. This is known as vaginal vault brachytherapy.

During each treatment session, a plastic cylinder (the applicator) is inserted into the vagina. The applicator is connected by plastic tubes to a machine that contains a small, radioactive seed (made of metal).

Next, this seed moves from the machine into the applicator where it delivers a targeted dose of radiation to the area affected by cancer.

After a few minutes, the seed is drawn back into the machine. The applicator is taken out of the vagina after each session.

This type of brachytherapy does not need any anaesthetic. Each treatment session usually takes only 20–30 minutes. You are likely to have 3–6 treatment sessions as an outpatient over 1–2 weeks.

If you are having radiation therapy as the main treatment and haven’t had a hysterectomy, the internal radiation therapy may involve placing an applicator inside the uterus.

This is done under anaesthetic or sedation, and may require a short hospital stay.

External beam radiation therapy (EBRT) directs the radiation at the cancer and surrounding tissue from outside the body.

For cancer of the uterus, the lower abdomen and pelvis are treated, but if the cancer has spread (metastasised), other areas may also be treated.

Planning for EBRT may involve several visits to your doctor to have more tests, such as blood tests and scans. Your radiation therapy team will give you instructions on preparing your bowel and bladder before planning scans and treatment sessions.

Each EBRT session lasts about 30 minutes, with the treatment itself taking only a few minutes. You will lie on a treatment table under a large machine known as a linear accelerator, which delivers the radiation.

The treatment is painless (like having an x-ray) but may cause side effects. If you are having EBRT, you will probably have daily treatments, Monday to Friday, for 5–6 weeks as an outpatient.

It’s very important that you attend all of your scheduled sessions to ensure you receive enough radiation to make the treatment effective.

• Fatigue –  Your body uses a lot of energy to recover, and travelling to treatment can also be tiring. The fatigue may last for weeks after treatment ends.
• Bladder and bowel changes – Radiation therapy can cause inflammation and swelling of the bowel (radiation proctitis) and bladder (radiation cystitis). Bowel movements may be more frequent, urgent or loose (diarrhoea), or you may pass more wind than usual. Less commonly, there may be blood in the faeces (poo or stools); talk to your treatment team if you notice this. You may also pass urine more often or with more urgency.
• Nausea and vomiting – Because the radiation therapy is directed near your abdomen, you may feel sick (nauseous), with or without vomiting, for several hours after each treatment. Your doctor may prescribe anti-nausea medicine to help prevent this.
• Vaginal discharge – Radiation therapy may cause or increase vaginal discharge. Let your treatment team know if the discharge smells or has blood in it. Do not wash inside the vagina with water or other fluids as this may cause infection.
• Skin redness, soreness and swelling – The vulva and the skin in the groin area may become sore and swollen. The area may look pink or red and feel itchy, and then peel, blister or weep. Your treatment team will recommend creams and pain relief to use. Wash the vulva with lukewarm water or weak salt baths; avoid perfumed products; and wear loose-fitting, cotton underwear.

Some side effects can continue for longer. Other side effects may not show up until many months or years after treatment. These are called late effects.

• Hair loss – You may lose your pubic hair. Sometimes, this can be permanent. Radiation therapy to the pelvis will not affect the hair on your head or other parts of your body.
• Bladder and bowel changes – Bowel changes, such as diarrhoea, wind or constipation, and bladder changes, such as frequent or painful urination, can arise months or years after treatment. Bleeding from the bowel or bladder can also occur. In rare cases, there may be loss of bowel control (faecal incontinence) or blockage of the bowel. Let your doctor know about any bleeding or if you have pain in the abdomen and difficulty opening your bowels (pooing).
• Lymphoedema – Radiation can scar the lymph nodes and vessels and stop them draining lymph fluid properly from the legs, making the legs swollen. This can occur months or years after radiation therapy. The earlier lymphoedema is found, the easier it is to treat. Look for early signs in the legs, including feelings of tightness or heaviness; tighter clothing; skin pitting; and swelling that comes and goes.
• Narrowing of the vagina – The vagina can become drier, shorter and narrower (vaginal stenosis), which may make sex and pelvic examinations uncomfortable or difficult. Your treatment team will suggest ways to prevent this.
• Menopause – If you are premenopausal, radiation therapy to the pelvis can stop the ovaries producing hormones, causing early menopause. Your periods will stop, you will no longer be able to become pregnant and you may have menopause symptoms.

Chemotherapy side effects vary greatly and depend on:

• the drugs you receive
• how often you have the treatment, and
• your general fitness and health.

Side effects may include:

• feeling sick (nausea)
• vomiting
• fatigue
• hair loss
• ringing or buzzing in the ears (tinnitus)
• numbness and tingling in the hands and feet (peripheral neuropathy).

Most side effects are temporary and steps can often be taken to prevent side effects or reduce their severity.

Chemotherapy can affect your immune system, increasing the risk of infection. If you develop a temperature over 38°C, contact your doctor or go immediately to the emergency department at your nearest hospital.

Common side effects of progesterone treatment include:

• breast tenderness
• headaches
• tiredness
• nausea
• menstrual changes, and
• bloating.

In high doses, progesterone may increase appetite and cause weight gain. If you have an IUD, it may move out of place and need to be refitted by your doctor.

Common side effects of immunotherapy include:

• fatigue
• being or feeling sick (nausea)
• skin rash and itching
• joint pain
• diarrhoea, and
• dry eyes.

Rarely, immunotherapy can affect the lungs, bowel or thyroid gland and these side effects can sometimes be life-threatening.

It’s important to let your treatment team know about any new or worsening side effects during or after treatment. Don’t try to treat side effects yourself.

Common side effects include:

• fatigue
• being or feeling sick (nausea)
• diarrhoea
• constipation
• sore mouth
• blood pressure changes
• appetite loss
• bleeding and bruising
• skin problems
• joint aches, and
• headache.

Less common side effects, such as heart problems and stroke, can also occur. It’s important to tell your doctor about any new or worsening side effects.